Wegovy/Ozempic/Semaglutide Weight Loss Injection Form
Please fill in the form below
I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform Dr. Taylor and Yvonne Alvarez RN of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. I agree to receive treatment from Dr. Taylor and or Yvonne Alvarez RN.
If I break any of the rules, or if my provider decides that this treatment is not benefiting me or helping me, this medicine may be stopped by my provider. I have talked about this agreement with my provider, and I understand the above rules.
Medical Director - Dr. Frank DiMotta, Dr. Jill Sohayda, and Dr. Jeff McKinley